Costs that bring you to your knees

Malad resident Jason Joseph had to make a near-impossible decision — he could either pay his daughter’s engineering fees or pay for his mother’s knee-replacement surgery.

His mother Irene, 65, called it too “expensive” and did not want to undergo it at all. “We went to more than 10 doctors; all of them quoted a price of Rs5-6 lakh. I had savings of just Rs1.5 lakh and my mother did not have health insurance,” said Joseph.

In May this year, Joseph learnt about Mahavir Medical Centre in Khar where a donor paid for the implants and Irene, who had been bedridden, started walking again. “Despite the donation, I spent more than a lakh for medicines and hospitalisation,” said Joseph who earns around Rs20,000 a month.

Health experts said the high cost of imported knee implants makes the option of a knee-replacement surgery out of the reach of the middle class. Doctors and hospitals pocket large profits one the implants — for instance, the import price of a complete knee-replacement kit is only Rs37,554, but customers are asked to pay at least Rs1.11 lakh.

An FDA report pointed out that the maximum retail price (MRP) of some implants is not even mentioned on the pack, which is sold at a price based on an agreement with the hospital.

After conducting the study, FDA officials made recommendations to the Central Drug Standard Control Organisation stating that there should be a cap on profits made by implant manufacturers and distributors.

Several doctors pointed out that since knee replacement is a common medical service, the cost of implants, bought in bulk by hospitals, should go down when more patients undergo the surgery.

“Hospitals, which do a huge number of knee replacements will end up buying the implants in large quantities and can therefore get a bargain on the purchases. But the savings made by hospitals do not always reach the patient,” said a senior orthopaedic surgeon from a private hospital.

With the distributors and hospitals pocketing huge profits, patients end up paying double the cost of the actual implant, said healthcare professionals.

Experts said that although insurance companies cover knee replacement costs, very few patients have medical insurance. People who are more than 65 years old are most likely to require knee replacement surgery.

“Most of the elderly do not have insurance; Even among the three out of ten who do, the amount insured is rarely more than two lakhs,” said Dr Shreedhar Archik, orthopaedic surgeon, Lilavati Hospital, Bandra.

Doctors reluctant to use Indian-made implants

Priyanka VoraMumbai: While a few Indian companies manufacture cheap implants, most knee-replacement surgeons shy away from using them. Doctors say they are unsure of the implants’ efficacy in the long run as most of these implants have been introduced in the market just four-five years ago. “Patients want an implant that will last 15 years. Indian-made implants have only been used for the last five years and we will have to wait for a decade before we know if they are as good as western-made implants,” said Dr Shreedhar Archik, orthopaedic surgeon, Lilavati Hospital, Bandra.

Dr Vivek Allahabadia, consultant orthopaedic surgeon at Hinduja Healthcare Surgical, Khar, recalled a case in which a patient who could not afford more expensive imported implants opted for an Indian brand. “Within just six years of surgery, the patient suffered from complications. Such patients cannot afford a revision surgery, so we do not compromise and use cheaper implants,” he said.

Ajay Kumar Pande, formerly a consultant to several multinational implant-manufacturing companies said the research that goes into designing the implants is expensive. “Most Indian companies create copies of the imported implants, affecting the quality,” said Pande.

However, public hospitals say differently. “As Indian-made implants are still a new product, we will have to wait and watch. But for those patients who cannot afford imported implants, Indian implants are the only option,” said Dr Mohan Desai, professor of the orthopaedic department at KEM Hospital, Parel.

Industry experts pointed out that the cost of knee implants will reduce only in the next decade, when there will be a substantial demand. “Unfortunately with newer technology, the cost of implants only increases. Hence, better technology used in the making of the implant will only increase the cost, which will be passed on to the patient,” said Dr Desai. He did however add that a few international companies have manufacturing units in India, which lowers the cost of the implant. Hospital administrators say the only negotiable cost in the bill for a knee replacement surgery is the surgeon’s fees. “Every surgeon decides his own fee; a cap is needed on the fees surgeons can charge,” said a member of the management of a private hospital.

Lower costs draw patients to Gujarat

Priyanka VoraMumbai: Soon after he retired, Gaurishankar Made, 68, started finding it difficult to walk. A trip to the orthopaedic surgeon told him he needed a total knee-replacement surgery. “We immediately checked for insurance and realised we could just recover a lakh. Doctors in Mumbai quoted more than Rs3 lakh for surgery on one knee,” said Sharan, Gaurishankar’s wife. Common friends suggested that the Mades consider an Ahmedabad hospital that was offering the same surgery at half the price. Gaurishankar visited Shalby Hospital in Gujarat and was soon back on his feet.

Doctors say the cost of implants is higher in Mumbai because of high taxes, which Gujarat does not have, making it a preferred medical health destination. “In Mumbai, octroi duty and VAT is levied 0at about 10% of the cost of the imported implant,” said a senior doctor.

As most patients are senior citizens, they find it difficult to pay for the surgery themselves and depend on their children. “The cost of the surgery was less in Ahmedabad than what doctors quoted in Mumbai. My daughter paid for the surgery,” said Pushpa Desai, 79, who had undergone a knee replacement surgery two years ago. At current rates, a total knee replacement package in a private Mumbai hospital costs anything between Rs4 and 5 lakh, but hospitals in Gujarat rarely quote more than Rs3.5 lakh.

“Patients do not want to compromise on quality, but cost is a definite concern. Both rich and also the middle class patients come to us knowing they will get affordable, but quality treatment,” said Dr Bharat Gajar, director outpatient services at Shalby Hospital, which claims to perform the highest number of knee replacement surgeries in the world. The hospital gets at least 80-100 patients from Mumbai in a month.

“Real estate cost affects hospital charges too; a five-star private hospital in the city would be more expensive than a hospital with the same facilities in Gujarat,” said a senior doctor.